Vaccine-Preventable Diseases: Situations Requiring Immediate Action Carrie A. Thomas, PhD Epidemiologist (VPD/IBD) Division of Infectious Disease Epidemiology West Virginia Bureau for Public Health www.dide.wv.gov (304) 558-5358

Objectives Overview of vaccine-preventable diseases that require rapid response & why it is important Consequences of non-response or untimely response Populations for special consideration Highlight key steps in the investigation

Measles – Why is it an Emergency? Endemic measles declared eliminated in the US in 2000 Almost 30% of cases experience complications Inflammation of the middle ear (7%) Pneumonia (6%) Encephalitis (0.1%) Hospitalization (19%) Death (0.3%) Susceptible populations at higher risk for disease and complications

Measles – Populations for Special Consideration Children < 1 year of age Susceptible immunocompromised patients Healthcare workers (HCWs) Increased risk of exposure and transmission through patient care Pregnant women High risk for pregnancy complications People travelling to places where measles are endemic

Measles – What to Do Immediately isolate suspect cases with airborne transmission precautions 4 days after rash onset in otherwise healthy individuals duration of illness in immunocompromised patients Confirm/rule out suspect cases rapidly through lab results Work with DIDE to submit sample to CDC High false positive rate of results in commercial labs

Measles – What to Do (cont.) Confirm immune status of exposed individuals Need written confirmation (verbal indication is not acceptable) Acceptable evidence of immunity Evidence of physician-diagnosed natural measles infection Documentation of two doses of measles containing vaccine, or A positive IgG antibody test for measles

Measles – What to Do (cont.) Post-exposure prophylaxis (PEP) for susceptible contacts, including HCWs Vaccination within 72 hours of exposure* Immune globulin, given within 6 days of exposure for Susceptible household or other close contacts Contacts < 1 year of age Pregnant women† Immunocompromised patients† *preferred method of PEP † vaccination contraindicated in these populations

Measles – What to Do (cont.) Susceptible persons do not receive PEP should be excluded for 21 days after rash onset in last case of measles Furlough susceptible HCWs from 5th-21st day after exposure, regardless of PEP Furlough ill HCWs for 4 days after development of rash

Rubella – Why is it an Emergency? Endemic rubella declared eliminated in the US in 1994 Complications are rare, occurring more frequently in adults than children However, arthralgia or arthritis may occur in up to 70% of adult women Encephalitis or hemorrhagic manifestations are rare Urgency comes from desire to prevent Congenital Rubella Syndrome

Rubella – Populations for Special Consideration Susceptible immunocompromised patients Children < 1 year of age Healthcare workers (HCWs) Pregnant women High risk for pregnancy complications Congenital Rubella Syndrome – affects up to 85% of infants infected during 1st trimester

Rubella – Congenital Rubella Syndrome (CRS) Can affect all organ systems; manifestations include Deafness - most common Cataracts & other eye defects Heart defects including holes in the walls or blood vessels; malformations of heart valves or blood vessels Microcephaly and/or mental retardation Bone alterations Liver and spleen damage Diabetes mellitus, progressive encephalopathy and autism have also been observed in children with CRS

Rubella – What to Do Immediately isolate suspect cases with contact precautions for 7 days after rash onset Confirm/rule out suspect cases rapidly through lab results Work with DIDE to submit sample to CDC for confirmation False positive IgM results seen in persons with parvovirus B19 infections, infectious mononucleosis, or a positive rheumatoid factor

Rubella – What to Do (cont.) Confirm immune status of exposed individuals Documentation of at least 1 dose of rubella-containing vaccine Positive IgG antibody test Born before 1957 Note: clinical diagnosis is unreliable and should not be considered when assessing immune status Confirm pregnancy status of exposed women

Rubella – What to Do (cont.) PEP for susceptible contacts, including HCWs Vaccination ASAP after exposure to prevent spread of disease, especially in settings where pregnant women may be exposed Vaccination is contraindicated 4 weeks prior to and during pregnancy and in immunocompromised individuals If pregnant woman is exposed Assess immune status

Diphtheria– Why is it an Emergency? Endemic in many parts of the developing world Approximately 50% of US adults are susceptible Formation of pseudomembrane over tonsils, pharynx or larynx can cause airway obstruction Complications include Inflammation of the heart muscle (myocarditis) Paralysis Inflammation of the middle ear Respiratory insufficiency

Diphtheria – Populations for Special Consideration Susceptible HCWs HCWs who are not up-to-date on Td boosters may become infected and spread disease to susceptible populations People travelling to places where diphtheria is endemic Immunocompromised patients and those with existing history of respiratory and/or heart conditions

Diphtheria – What to Do Isolate suspect cases with droplet precautions for 48 hours after beginning antibiotics Confirm diagnosis through lab results Work with DIDE to submit sample to CDC Do not wait for lab confirmation to treat those meeting clinical case definition with antibiotics & diphtheria antitoxin (only available from CDC since 1997)

Diphtheria – What to Do (cont.) Assess vaccination history in case/contacts. Administer appropriate dose(s) of DTaP/DTP/DT/Td/Tdap Submit samples for culture for and administer prophylactic antibiotics to close contacts These recommendations apply to respiratory diphtheria Cutaneous diphtheria is not a reportable condition Transmitted through contact with skin lesions

Meningococcal Meningitis – Why is it an Emergency? Infection can progress rapidly and result in death 10-14% case-fatality rate Approx 40% meningococcal disease cases present as bacteremia, Of those surviving invasive disease, 10-20% experience sequelae, including limb loss from gangrene, extensive skin scarring or cerebral infarction 70% of secondary cases occur within 7 days

Meningococcal Meningitis – Populations for Special Consideration College freshman living in dorms Military recruits People travelling to countries where meningococcal disease is hyperendemic or epidemic Persons with conditions leading to decrease immune system functions, including terminal complement component deficiencies anatomic or functional asplenia

Meningococcal Meningitis – What to Do Trace patient contacts within 7 days of symptom onset in index patient Close contacts defined as Household members (including dormitory room and barrack roommates) Childcare center contacts Persons directly exposed to patient’s oral secretions by kissing, mouth-to-mouth resuscitation, or endotracheal intubation/tube management Add from red book

Meningococcal Meningitis – What to Do (cont.) Offer PEP as soon as possible (preferably within 24 hours) If given more that 14 days after symptom onset in index patient, PEP is probably of limited or no benefit Offer PEP to exposed HCWs, but think before you offer PEP You probably don’t need to provide PEP to the receptionist who checked the patient in

Invasive Haemophilus Influenzae b (Hib) – Why is it an Emergency? Before vaccine, 15-30% of survivors experienced serious complications Hearing impairment Severe permanent neurologic consequences Mental retardation Seizure disorder Cognitive & developmental delay Paralysis Rapid identification important for early vaccination and chemoprophylaxis of susceptible contacts

Hib – Populations for Special Consideration Children under 5 years of age Immunocompromised children Older children and adults who were not vaccinated in childhood and have the following conditions Functional or anatomical asplenia Immunodeficiency from IgG2 subclass deficiency Immunosuppression from cancer chemotherapy HIV Hematopoietic stem cell transplant

Hib – What to Do Isolate suspected cases with droplet precautions until 24 hours after starting antibiotics Confirm diagnosis and have isolate serotyped (OLS) Offer PEP for all household contacts as soon as possible With at least 1 contact < 4 years old who is unimmunized or incompletely immunized With a child younger than 12 months who has not received the primary series With an immunocompromised child (regardless of immunization status

Hib – What to Do (cont.) PEP should also be provided for Nursery school/childcare center contacts when > 2 cases occur within 60 days PEP is NOT recommended for Contacts in households with no children < 4 years old except index case Contacts in households where Members 12-48 months old are fully vaccinated Members <12 months old have received primary series of Hib immunizations Nursery school/childcare center contacts of 1 index case Pregnant women

Mumps – Why is it an Emergency? 20-40% infections asymptomatic Major cause of sensorineural deafness in children Complications more common in adults Meningoencephalitis Orchitis , oophoritis, mastitis Permanent consequences are rare Susceptible HCW are who you need to be concerned about Define parotitis

Mumps – What to Do Isolate cases with droplet precautions for 5 days after onset of parotitis Evaluate immune state of exposed contacts Written documentation of vaccination Positive mumps IgG Lab confirmation of disease Birth before 1957 (except in healthcare setting)

Mumps – What to Do (cont.) Susceptible children should receive 2 doses MMR Susceptible children should be excluded from school until the 26th day after onset of parotitis in the last case HCWs without evidence of immunity should be furloughed from the 9th-25th day after exposure All HCW should be alert for symptoms of mumps 12-25 days after exposure, regardless of vaccination status

Pertussis during Pregnancy Pertussis can cause severe illness and death in infants Any woman who might become pregnant is encouraged to receive a single dose of Tdap Women who have not received Tdap should receive a single dose in the immediate postpartum period

Pertussis during Pregnancy (cont.) Pregnant women should receive a single dose of Tdap during an outbreak Preferably in the 2nd or 3rd trimester to avoid coincidental association of vaccination and spontaneous termination of a pregnancy, which is more common in the 1st trimester Vaccination during pregnancy can provide some protection for newborns

Varicella during Pregnancy Primary infection with VZV in pregnant women is rare Varicella in pregnancy is associated with VZV infection of the fetus Low birth weight Skin scarring Malformed limbs Mental retardation Vision problems

Varicella during Pregnancy (cont.) Vaccination contraindicated during pregnancy Women should be vaccinated before they attempt to become pregnant If not immune pre-pregnancy, should be vaccinated immediately post-partum Immune globulin can prevent or reduce severity of disease if given within 96 hours of exposure

Summary Isolate case patient Inform appropriate agencies – DIDE, CDC Confirm diagnosis with appropriate lab testing Trace contacts and assess immunity Provide appropriate PEP

References Manual for the Surveillance of Vaccine-Preventable Diseases, 4th edition, CDC, 2008 Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book), 12th edition, CDC, 2011 Red Book: 2009 Report of the Committee on Infectious Diseases, 28th edition, American Academy of Pediatrics, 2009 www.mayoclinic.com